Patient safety and the quality of healthcare they receive can be improved by evaluating existing data from various sources such as the patient’s health record, laboratory findings, registration, administration and incident reports. One area that leaders are constantly striving to improve is the number of patient falls that occur within their area, especially now that they are no longer reimbursable. It is important to adopt and use a specific definition for a fall, otherwise the meaning is left too open and may be interpreted in various ways.
The WHO (World Health Organization) defines a fall as “inadvertently coming to rest on the ground, floor or other lower level, excluding intentional change in position to rest in furniture, wall or other objects” (WHO, 2007). The purpose of this paper is to show how leaders analyze the data that is available to them and use that to develop and implement strategies to improve patient quality and safety. Data Overview There are many separate factors that collectively help determine a patient’s fall risk. On the unit we are evaluating for this assignment all of the patient rooms are private.
Although this is the best way to ensure patient privacy and decrease the risk of spreading a contagion, a private room can actually be a deterrent to patient falls. If there are two patients assigned to a single room a nurse will be present in that room about twice as much as they would be in a single occupancy room. The other patient and any visitors they had would be extra eyes watching the patient at-risk of falling and they could remind them to call for help if they needed to get up or even call for a nurse themselves and warn us of their roommate’s activity.
There are also about 12% of the patients on the unit who are either confused or disoriented. Patients who suffer from ailments that affect them mentally have an increased risk of sustaining an injury. Studies have shown that falls happen more often to people who are confused or who have multiple medical problems (Bates, Pruess, Souney, & Platt, 1995). Sometimes sun downing also takes place in a small number of patients as the evening progresses. Diuretics are used by almost all of the patients currently on the unit.
If they received an evening dose of the medicine or if they were given it very late, they are likely to spend a large amount of their night feeling the medications effects. The fact that 68% of the patients are women implies that if they need to use the restroom during the night, they will more than likely have to stand up and get out of the bed. They will need to call for assistance, but they may start to feel like they are calling too often. This could lead to the patient attempting to ambulate on their own, which is not a good idea. Every time the patient stands up they are increasing their chance of suffering a fall.
A cardiac diagnosis alone puts the patient into a higher risk group. Many cardiac conditions can lead to syncopal episodes. Sudden drops in blood pressure upon standing account for a large percentage of falls. Orthostatic hypotension, also known as postural hypotension, and postprandial hypotension are both examples of conditions involving blood pressure drops (Carey & Potter, 2001). Carey and Potter also write that carotid sinus syndrome is the likely cause of many unexplained falls in approximately 1/3 of people that are over the age of 65.
Other cardiac issues that can lead to a patient fall are migraines, vasovagal syncope, pulmonary embolism, transient ischemic attacks, tamponade, aortic dissection, and valvular stenosis, to name a few (Carey & Potter). There are so many different elements that are contributing to the patient being at an increased risk of falling, that falls prevention measures must take all the variables into account to be effective at all. It looks as if the most falls, 15 of them, occurred from 7a-11a on the weekends.
One could interpret the information several ways but what I believe to be the case is that the weekend staff are not as good at patient afety or perhaps there are less of them to watch over the patients so more of them are falling. The time of 7a-11a is when the patients are usually their busiest so they are up more and have more opportunities to fall. The recent loss of the aide from 11p-7a is probably also at fault. The night-shift nurse may not have had time to bathe the patient, walk them to the restroom at the end of shift, or check to see if their bed and brief was dry so the patient could have attempted to complete these tasks alone while the day-shift nurse is preparing morning medicines.
The next highest number of falls is 14 and those also happened on the weekend, but they were from 3a-7a. Again the unexperienced or decreased staff on the weekends partly to blame and not having an aide to assist the nurses at this time is the major culprit. I know where I worked, 3a-7a was our busy time yet one could not keep an eye on all of the patients at once, so falls were a definite possibility. Quality Improvement Plan Organizations are able to track patient outcomes in a wide variety of areas.
Those findings are then compared and examined against other results to gauge how well the system is functioning. Problems within the process are discovered and then methods or steps are developed to correct any potential issues that may arise while in pursuit of improved patient quality and safety. In order to measure how well a standard or process is performing, tools called indicators are commonly used (Sullivan, 2012). The quality management process that appeals to me is the DMAIC method that compares the organization’s performance against standards that have already been set (Sullivan, 2012).
Sullivan states that raising the level of healthcare and improving the quality of it is the goal behind process improvement systems. The steps Sullivan outlines in the DMAIC method are to define what measurements will show success, then measure where the baseline currently is and then analyze the results that are found, after that then they need to do better, improve the performance and lastly control and keep the performance at the new level. The number of falls on a unit, and the reason for them occurring, can be monitored by viewing the incident reports and reviewing what took place.
By discovering the processes that were in place when the fall took place and where the breakdown was, the hope is that future problems such as that one will be averted. Dashboards are like a scorecard and they offer an abundance of data which is helpful in many ways, such as determining staffing needs and providing nurses an idea of how well the patients are satisfied with the care they are receiving (Sullivan, 2012). A risk management program dedicated to decreasing the number of falls should be developed.
For the program to be successful, it requires commitment and full participation from every staff member, especially the chief nursing administrator because how they feel about it will have an influence on the participation of the rest of the staff members (Sullivan, 2012). The program would entail identifying, reviewing, analyzing, planning, and evaluating the available data and after that has been done, a plan is developed to reduce the number and severity of occurrences (Sullivan).
I also believe performing a root-cause analysis would provide a lot of useful, constructive advice and information. Leadership Characteristics The characteristics of a leader are very important and they could positively or negatively affect patient fall rates. Sullivan writes that “the nurse manager sets the tone that contributes to a safe and low-risk environment” (2012, p. 81). To help decrease risks to the patient, develop an environment that is patient-focused and that instills the belief in them that the care is focused on them and only has their best interests in mind (Sullivan).
Sullivan wrote that providing a good and thorough orientation for patients upon admission to the unit creates a feeling of independence and confidence in the staff members and in the unit as a whole. Another important feeling or sense that is important to convey to the employees that work there is for them to feel they have the freedom and administrative support to report near misses and mistakes that may happen without fear of being reprimanded.
If the environment is relaxed and fingers are not pointed and punishments are not handed out for every mistake that is made, then more accurate reporting of occurrences will probably take place. Although nurses are not to be blamed and reprimanded for making a mistake, they should also not believe that they can get by with doing anything they feel like, and remember they are still accountable for their actions. With a forgivable and understanding atmosphere as the core, then the mishaps that do take place can be discussed and used as a learning and growing experience.
Summary It is crucial that a solution to the increased number of falls occurring on the unit is found. The solution should be based on what research has discovered offers the patient the best possible outcomes. Quality of care is thought to improve when evidence-based practices are used. However it is accomplished, all of an organization’s staff need to be vigilant and take an active role in doing all they can to keep each and every patient safe and off the floor.